|Year : 2013 | Volume
| Issue : 2 | Page : 155-158
Experience with diagnostic laparoscopy for gynecological indications
Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, and Life Fertility Centre, Life Specialist Hospital Limited, Nnewi, Nigeria
|Date of Acceptance||27-Feb-2012|
|Date of Web Publication||6-Apr-2013|
J I Ikechebelu
P.O. Box 244, Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Diagnostic laparoscopy is an endoscopy procedure, which has become indispensable in the evaluation of the female reproductive organs especially in infertility.
Aim: Experience with conversion to open laparotomy is presented and ways of averting this complication are discussed.
Settings and Design: A retrospective study was performed.
Materials and Methods: All the 1654 diagnostic laparoscopies performed at a private fertility center over a 10-year period (January 2000 to December 2009) were analyzed for indications, cases of conversion to open laparotomy, and measures taken to prevent this complication.
Statistical Analysis Used: Simple percentage method was used.
Results: Infertility was the commonest indication for 1627 (98.4%) procedures, while primary amenorrhoea and chronic pelvic pain were responsible for 20 (1.2%) and 7 (0.4%) procedures, respectively. There was no mortality in this series. There was conversion to open laparotomy due to hemorrhage in only 2 (0.12%) procedures and this happened at the first year of practice.
Conclusions: The low rate of conversion was attributed to the surgeons experience, proper patient selection, and the use of Palmers point for insufflation in some patients with previous pelvic surgeries and use of supraumbilical access in patients with pelvic masses. Diagnostic laparoscopy for gynecological indications is safe and wider application of this modern technology is recommended for our practice.
Keywords: Amenorrhoea, conversion, hemorrhage, infertility, laparoscopy
|How to cite this article:|
Ikechebelu J I. Experience with diagnostic laparoscopy for gynecological indications. Niger J Clin Pract 2013;16:155-8
| Introduction|| |
Diagnostic laparoscopy is best performed by a reproductive specialist as surgical treatment and can often be done during diagnostic evaluation. It is performed to evaluate the female reproductive system or other gynecological complaints like chronic pelvic pain. ,, Diagnostic laparoscopy is traditionally done in operating theatre under general anesthesia;  though there has been reports of use of local anesthesia with sedation for office laparoscopy. , The procedure takes between 20 and 30 min and the patients are usually discharged from the hospital the same day.
The complications associated with laparoscopic procedures include damage to other abdominopelvic organs, hemorrhage, and unintended conversion to open surgery, although the later is uncommon. ,, Like any other surgeries, it can also be complicated by anesthetic problems and postoperative infection. 
In this study, experience with diagnostic laparoscopy and particularly conversion to open laparotomy is presented and ways of averting this complication are discussed.
| Materials and Methods|| |
This is a 10-year review of diagnostic laparoscopy performed at a private fertility center from January 2000 to December 2009. Since the year 2000 to date, this center offers weekly sessions for diagnostic laparoscopy for fertility evaluation and other gynecological indications. It receives referrals from neighboring towns/states and has developed into a training center in minimal access surgery.
During the laparoscopy sessions, the patients and their spouses/relations are counseled on the procedure and they sign an informed consent. All the procedures were performed following an overnight fast and under ketamine general anesthesia by the author. 
During the procedure, the patient is anesthetized and placed in lithotomy trendelenburg position. The abdomen, perineum, and vagina are cleansed and draped leaving only the umbilical area and the vulva. Vaginal examination is done and the cervix exposed and grasped with a pair of vulselum forceps transversely. Uterine cannula is introduced via the external cervical os and anchored to the vulselum forceps. An assistant usually performs this vaginal aspect and also injects the methylene blue dye in infertility cases during the procedure. Subsequently, the access point for the first port is determined and in most cases the infraumbilical area (smiling incision) is preferred. A stab skin incision is made on the area and the Verress' needle introduced for CO 2 insufflation to achieve the desired pneumoperitoneum. Then, the incision is extended to 11 mm and trochar and cannula were introduced. The trochar is withdrawn and the laparoscope passed into the peritoneal cavity for examination of the abdominal and pelvic organs. A second port may be required to pass an instrument that will expose the structures for proper visualization.
Methylene blue dye is then injected via the uterine cannula to access tubal patency. After this, the instruments and later the telescope and cannula are withdrawn and the port wound(s) closed with an absorbable suture in a subcorticular manner. Dressing is applied and patient is discharged home on full recovery from the anesthesia. The procedure is recorded on video and available for review.
| Results|| |
A total of 1654 diagnostic laparoscopies were performed during the study period. The indications for the procedures were infertility (1627; 98.4%), primary amenorrhoea (20; 1.2%), and chronic pelvic pain (7; 0.4%), respectively. No mortality was recorded in this series. Only two conversions due to hemorrhage out of 124 procedures were encountered in the first year of practice, given a conversion rate of 1.61% for the first year of practice. There were no conversions in the other years given a conversion rate of 0.12% for the 10-year study period. The details are shown in [Table 1].
The details of the two conversions are as follows:
Mrs. C.E. was a 32-year-old nulliparous woman who presented at Life Fertility Center on 3/4/2000 with a 1 year history of infertility and lower abdominal mass. The husband had a normal seminal fluid analysis result with a sperm count of 32 × 10 6 /ml and 60% actively motile sperms. She had a 28-day cycle with 5 days normal flow and her last menstrual period (LMP) was on 24/3/2000. She had splenectomy in 1995 via an abdominal incision extending from below the xiphy sternum to a point above the symphysis pubis. Abdominal examination revealed a uterine mass equivalent to 16 weeks gestation size. She was scheduled for laparoscopy and dye test to evaluate both tubal and peritoneal factors.
Diagnostic laparoscopy was performed on the patient using ketamine general anesthesia. The following findings were observed. Bulky retroverted uterus with multiple fibroid masses (intramural and subserous). The uterine cavity was 9 cm in depth and the external os was nulliparous. There was a small puncture on the anterior fibroid mass by the Verres' needle with leakage of blood into the peritoneal cavity. Both fallopian tubes and ovaries were shielded from view by the multiple fibroid masses and no evidence of dye spillage was noted. There were no pelvic adhesions. The patient recovered fully from anesthesia but continued to complain of weakness. Six hours postlaparoscopy, her vital signs revealed a rising pulse rate and falling blood pressure of 80/40 mmHg. There was also abdominal distension with tenderness and guarding. Abdominal paracentesis yielded blood and a diagnosis of hemoperitoneum was made. An emergency laparotomy was performed and the bleeding was confirmed to be from the puncture site. She then had myomectomy and received 3 units of whole blood. She had an uneventful recovery and was discharged home on the 8 th postoperative day after removal of the skin sutures. Two months later, she became pregnant and went ahead to deliver a live female baby at term.
Mrs. A.A. was a 34-year-old nulliparous woman who presented at Life Fertility Center on 13/08/2000 with a 4 year history of primary infertility. Her husband had a normal seminal fluid analysis with a sperm count of 45 × 10 6 /ml and 75% progressive motility. She had a 28-day cycle with 3-4 days of menstrual flow and her LMP was on 6/08/2000. She was obese with a body mass index (BMI) of 28 and no palpable abdominal mass. She had a hysterosalpingogram (HSG) that showed bilateral tubal occlusion and was then scheduled for diagnostic laparoscopy. The hematological parameters were normal.
Diagnostic laparoscopy was performed using ketamine general anesthesia. The following findings were observed. There was an active arterial bleed from the uterine mass. Inadvertently, the Verres' needle had perforated a vessel running superficially on one of the uterine fibroid masses. We had no instrument for operative laparoscopy or for cauterization. The procedure was abandoned for an emergency laparotomy. She had a successful laparotomy and myomectomy and was discharged home on the 8 th postoperative day.
| Discussion|| |
This conversion rate of 0.12% in my 10 years of performing diagnostic laparoscopy is lower than reports from other centers. ,, The conversions took place in the first year of practice and agree with presentation by other laparoscopic surgeons that the rate of conversions/complications is inversely related to the surgeon's experience.  This is in keeping with the long learning curve for laparoscopic surgery.
The conversions in this study were due to hemorrhage caused by the Verres' needle injury to uterine fibroid mass. Other factors or complications that can lead to conversion include damage to a major vessel, bowel injury, the nature of the procedure, the overall patient health, level of laparoscopic complexity, BMI greater than 30 kg/m 2 , suspicion of malignancy, history of laparotomy, presence of adhesions, and intraoperative technical difficulty. ,
These were not encountered in this series. The introduction of the Verres' needle via the infraumbilical access point in the presence of pelvic mass (though unnoticed in case 2) predisposed to these complications. Instead, the Palmers point (2-3 cm below left coastal margin, at the midclavicular line) should have been used for introduction of Verres' needle to avoid this complication, or open method using Hanson's cannula should have sufficed. Indeed, I had subsequently used the Palmers point even for pelvic masses up to 18 weeks without similar complication. Second, I now perform pelvic ultrasonography for all patients scheduled for diagnostic laparoscopy to assess for pelvic masses and decide on the access point for the Verres' needle. This is recommended since some pelvic masses may not be palpable per abdomen especially in obese patients as reported in case 2. Third, supraumbilical access point can also be used to minimize risk of trauma to pelvic masses. These three approaches have been used effectively in my practice without any further conversions.
The hemorrhage would have been controlled or control attempted laparoscopically with injection of vasopressin or cauterization. These options were not used in the cases presented because the center was then equipped for only diagnostic laparoscopy. It is argued that diagnostic laparoscopy alone without facilities for operative laparoscopy should not be done as this will amount to double exposure to anesthesia if the pathologies found at diagnostic laparoscopy will be dealt with at another operation. However, diagnostic laparoscopy offers the young laparoscopic surgeon an opportunity to learn the art of laparoscopy, especially the hand-eye coordination and movement appreciation. Also diagnostic laparoscopy for fertility evaluation is pertinent in our environment where there is high incidence of tubal and peritoneal factors as causes of the female infertility. 
| Conclusion|| |
Diagnostic laparoscopy is safe and conversions to open laparotomy especially from hemorrhage is rare and can be avoided by proper patient selection and use of Palmers point for insufflation, supraumbilical access point, or open (Hanson's) technique especially in those patients' with pelvic masses or previous abdominopelvic surgeries.
| Acknowledgments|| |
My sincere thanks go to the different medical officers and resident doctors who have worked with me and assisted me in performing the laparoscopy procedures at different times. I also thank the theater staff of the hospital for their support and cooperation during the ten years of this review.
| References|| |
|1.||Milingo S, Protopapas A, Kallipolitis G, Drakakis P, Makrigiannalais A, Liapi A, et al. Laparoscopic evaluation of infertile patients with chronic pain. Reprod Biomed Online 2006;12:347-53. |
|2.||Odusoga OL, Oloyede OA, Adewunmi AA, Fakoya YA. Experience with the laparoscope in the evaluation of infertile women in sagamu. Niger J Clin Pract 2002;5:127-9. |
|3.||Ajayi AB, Babarinsa IA, Adewole IF. Day care diagnostic laparoscopy in infertility evaluation. Niger Q J Hosp Med 1998;8:288-90. |
|4.||Ikechebelu JI, Udigwe GO, Obi RA, Joe-Ikechebelu NN, Okoye IC. The Use of Simple Ketamine Anaesthesia for Day-case Diagnostic Laparoscopy. J Obstet Gynaecol 2003;23:650-2. |
|5.||Palter SF, Olive DL. Office microlaparoscopy under local anesthesia for chronic pelvic pain. J Am Assoc Gynecol Laparosc 1996;3:359-64. |
|6.||Dugan KA. Diagnostic laparoscopy under local anesthesia for evaluation of infertility. J Obstet Gynecol Neonatal Nurs 1985;14:363-6. |
|7.||Sokol AI, Chuang K, Milad MP. Risk factors for conversion to laparotomy during gynecologic laparoscopy. J Am Assoc Gynecol Laparosc 2003;10:469-73. |
|8.||Fanning J, Hossler C. Laparoscopic conversion rate for uterine cancer surgical staging. Obstet Gynecol 2010;116:1354-7. |
|9.||Chi DS, Abu-Rustum NR, Sonoda Y, Awtrey C, Hummer A, Venkatraman ES, et al. Ten-year experience with laparoscopy on a gynecologic oncology service: Analysis of risk factors for complications and conversion to laparotomy. Am J Obstet Gynecol 2004;191:1138-45. |
|10.||Ikechebelu JI, Obi RA, Udigwe GO, Joe-Ikechebelu NN. Comparism of Carbondioxide and Room Air Pneumoperitoneum for Day-case Diagnostic Laparoscopy. J Obstet Gynaecol 2005;25:172-3. |
|11.||Ikechebelu JI, Adinma JIB, Ikegwuonu SO, Orie EF. Clinical Correlates of Unexplained Infertility in Southeastern Nigeria. Trop J Obstet Gynaecol 2002;19:8-11. |
|This article has been cited by|
||Comparison of Laparoscopy and Laparotomy in Early-Stage Endometrial Cancer: Early Experiences from a Developing Country
| ||Yusuf Cakmak,Duygu Kavak Comert,Isik Sozen,Tufan Oge |
| ||Journal of Oncology. 2020; 2020: 1 |
|[Pubmed] | [DOI]|
||Mortality rates in benign laparoscopic and robotic gynecological surgery- a systematic review and meta-analysis
| ||Sadikah Behbehani,Elena Suarez-Salvador,Matthew Buras,Paul Magtibay,Javier Magrina |
| ||Journal of Minimally Invasive Gynecology. 2019; |
|[Pubmed] | [DOI]|
||Laparoscopy Using Room Air Insufflation in a Rural African Jungle Hospital: The Bongolo Hospital Experience, January 2006 to December 2013
| ||Zachary O’Connor,Marco Faniriko,Keir Thelander,Jennifer O’Connor,David Thompson,Adrian Park |
| ||Surgical Innovation. 2017; 24(3): 264 |
|[Pubmed] | [DOI]|
||The role of diagnostic laparoscopy in gynecology
| ||Raquel Togni,Cristina Laguna Benetti-Pinto,Daniela Angerame Yela |
| ||Sao Paulo Medical Journal. 2016; 134(1): 70 |
|[Pubmed] | [DOI]|
||The Role of Minimally Invasive Gynecologic Surgery in Sub Saharan Africa
| ||Oluwatosin Onibokun,Adeline Boatin,Khady Diouf |
| ||Current Obstetrics and Gynecology Reports. 2016; 5(4): 333 |
|[Pubmed] | [DOI]|